“Tele-Rehabilitation:Background & Use Case Examples”

Colonel (Ret.) Ronald Poropatich, MD, MSBambang Parmanto, PhD

Ellen Cohn, PhDUniversity of Pittsburgh

16 December 2020

“Wherever they happen to be in the world or on the battlefield, telemedicine and satellite communications now enable them to receive expert medical help. The U.S. military is also using telemedicine globally to aid civilians stricken by natural disasters.”

https://futurehealthcaretoday.com/how-telemedicine-serves-our-military/

Tele-Rehabilitation

• Terminology used to describe telerehabilitation is similarly broad.

– Some terms specifically refer to individual rehabilitation disciplines, (e.g., teleaudiology, telespeech, tele-occupational therapy, and tele-physical therapy).

– More generic terms, such as teletherapy, telehealth (endorsed by the American Occupational Therapy Association and the American Physical Therapy Association), and telepractice (endorsed by the American Speech-Language- Hearing Association) are also used, allowing for a broader focus on populations and activities, such as educational settings and wellness promotion in addition to rehabilitation.

Rehabilitation

• Traumatic Brain Injury

• Spinal Cord Injury

• Cerebrovascular Accident (Stroke patients)

• Orthopedic & Neurological Disorders– amputation, total joint replacement, aneurysm, anoxia, arteriovenous

malformation, encephalopathy, Guillian-Barré syndrome, multiple sclerosis, cancer, spinal or brain tumor, post-polio syndrome,

• Specialty Services: Occupational, Physical & Speech– each form of rehabilitation serves a unique purpose in helping a

person reach full recovery, but all share the ultimate goal of helping the patient return to a healthy and active lifestyle.

What Do We Call “It” (Tele)?

• Telemedicine: American Telemedicine Association [ATA]Teledermatology; teleradiology; tele-ICU; tele-neurology; tele-psychiatry; tele- pediatrics; tele-primary care; tele-nursing; tele-dentistry; telerehabilitation

• Telehealth: American Occupational Association/AOTA], sometimes ATA

• Telerehabilitation: Physical Therapy, Occupational Therapy, Speech and Hearing, sometimes ATA

• Telepractice: American Speech-Language Hearing Association

Why did ASHA choose Telepractice?

• The profession works in medical AND non-medical sites

• School-based practice

• Educational, rehabilitation, medical, and health conditions

• Telepractice includes:• Tele-speech

• Tele-audiology

• Tele-AAC• Emerging –Assistive and Augmentative Communication

• Sometimes includes Vendors

Problems with Inconsistent Terminology

•Perpetuates professional silos

•Awkward when advocating for greater reimbursement

• Legislative language must be broadly inclusive

•When an article or grant proposal is authored bydifferent professionals: Whose terminology prevails?

Basic Tele-Types

•Asynchronous• “Store and forward” [e-mail, test results, recorded

sessions, etc.]

• Synchronous• At the same time

•Hybrid – term has two meanings• Combination of asynchronous and synchronous• Any combination of telepractice (asynchronous and/or

synchronous) and in-person care.

If you know one state…you know one state.

State Licenses for Rehab. Professionals Are Required in Almost Every State.

[Exception: VA/Dept of Defense]

• Requirements can change rapidly and without notice.

• A state license is needed where the practitioner resides, AND where the

patient/client resides.

• If a state has not established regulations on telepractice, then contact the

licensure board for further guidance and ask for written verification.

• Notify your malpractice insurance carrier.

• State licensure compacts are developing. The Federation of State Medical Boards reported that as of April 2020, that 44 states had waived in-state licensure requirements for telehealth. Rehab compacts lag behind.

Privacy and Safety are Paramount

• Where is your client TODAY? (address?)

• What are the emergency numbers? Emergency contacts?

• When does a session end? (When the client leaves the room or logs off.)

• Is confidentiality possible?

• Who is in the room?

• Is anyone in the room who should not be on video?

• Does the technology enable HIPAA compliance?

An Excellent Open Journal Article for Privacy and Security

• Watzlaf, V.R., & Ondich, B., VoIP for Telerehabilitation: A Pilot Usability Study for HIPAA Compliance, International Journal of Telerehabilitation Vol. 4, No. 1 Spring 2012

(10.5195/ijt.2012.6096)http://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6096/6390

Well Trained E-Helpers/Facilitators are Crucial to Success

• They are sometimes family members, companions, school personnel, trained technicians, or a profession’s assistants

• An excellent resource:Schlaak, Hannah M., "PROFESSIONAL COMPETENCIES FOR E-HELPERS: ATELEPRACTICE RESOURCE" (2018). Theses and Dissertations--Communication Sciences and Disorders. 12. https://uknowledge.uky.edu/commdisorders_etds/12

https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1012&context=com mdisorders_etds

Plan for Technology Glitches• Assess the infrastructure

• Will the teacher, therapist and student have a webcam, computer, adequate internet connectivity and a phone? Printer/scanner?

• Are the lesson materials accessible?

• Are they transmitted ahead of the session? Who is to print them out? Do they take a long time to load?

• How does communication occur when the video doesn’t work?

• An external channel?

• An agreed upon protocol?

• Scan the environment for potential threats

Telerehab: A “win-win-win”Benefits consumers (i.e., students/schools etc.)

Saves timeSaves money (travel; childcare, lost wages) Provides clinical expertise

Reaches rural settings (IF connectivity is available)

Research shows that it works

Benefits the clinicianProvides additional income

Avoids travel

Expands expertise

Benefits the clinical practice/businessAvoids cancellations

Generates income

• Access research from: https://www.asha.org/About/Telepractice-Resources-During-COVID-19/

• ASHA Evidence Maps: research on the use of telepractice

• ASHA Practice Portal: information about telepractice as a service deliverymodel

• Browse free telepractice articles from ASHA Journals

• Needed research:

• Patient selection

• Hybrid care

• Training requirements

• Economic impact on the workforce

Research Shows: Equivalent or Better Results

ASHA – American Speech Language Hearing Association

A Complicated Environment – Many Influencers

• State Professional Licensure Boards & National State Boards• Professional Associations: AMA, ASHA, AOTA, APTA…

• Professional-Trade Associations: ATA, Healthcare Information and Management Systems Society | HIMSS

• Federal Government: US Congress, CMS, FCC, FDA and other regulatory agencies

• State Governors and State legislative bodies

• K Street (Alliance for Connected Care)• Anthem, CVS Health, Walgreens, TelaDoc, Specialists on Call, Verizon,

WellPoint, HealthSpot, Doctor on Demand, Welch Allyn, and MDLIVE, Care Innovations and Cardinal Health.

• Technology Is Developing Faster than Policy/Big Money/COVID

Train, Train, Train –and Test the Training in “Tabletop Exercises”

• “We don't rise to the level of our expectations, we fall to the level of our training.”— Archilochus, a Greek lyric poet from the island of Paros who livedfrom 680 BC until 645 BC.

• Do workers and customers have the needed technology?

• Do they know how to use it?

• How will technical support be delivered?

The Facts About Trauma in the U.S.

■ Trauma is the #1 cause of death for Americans between 1 - 44 years

■ Trauma is the #3 cause of death overall.

■ Each year, trauma accounts for 41 million ER visits and 2M hospital admissions.

■ Trauma injury accounts for 30% of all life years lost.

■ The economic burden of trauma is more than $406 billion annually.

■ Each year, more than 180,000 people lose their lives to trauma.

Source CDC, updated February 2018

TBI Facts• 1.7 million sustain a TBI each year in the US: 52,000 die; 275,000

hospitalized;

• Causes of TBI?– Falls (35.2%);

– Motor vehicle-traffic crashes (17.3%);

– Struck by/against events (16.5%);

– Assaults (10%); and

– Unknown/Other (21%).

– Blasts are a leading cause of TBI for active duty military personnel in war zones.

• Highest risk for TBI?– Males are about 1.5 times as likely as females to sustain a TBI.

– The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.

• Costs of TBI?– Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated

$60 billion in the United States in 2000.

• CDC estimates that at least 5.3 million Americans currently have a long-term or lifelong need for help to perform activities of daily living as a result of a TBI

Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek.Journal of Head Trauma Rehabilitation1999;14(6):602-15

How do we leverage the mobile health development for TBI and PTSD conditions into a

broader context of Rehabilitation Care (spinal cord injury, polytrauma) for individuals confined

to a wheelchair or prosthetic?

Tele-Rehabilitation for Polytrauma Patients- Incremental Development Schema

TBI PTSD Prosthetics

Wheelchair

Memory

Attention

Cognition

Sleep

Anxiety

Depression

Gait monitoring

Machine-Body interface

Skin breakdown

Machine-Body interface

Skin breakdown

A view inside the Genium bionic prosthetic system technology [Picture: Ottobock]

Advanced Prosthetic Technology

Genium bionic prosthetic leg system [Ottobock]

Sensors embedded in liner:

- Temperature

- Pressure

- Moisture

Sensor configuration integrated with mobile devices & energy harvesting

Energy harvesting

(to power sensors)

Actuator positioning

Sensors:

- enhance gait training

Data flow

Provider enabled

home monitoring

Server

Clinicians

Challenge:How do you monitor 3 prosthetics in

an integrated way?

Applications for Supporting Self-care in Management of Chronic and Complex Conditions: SCI

Parmanto et al. (2013) IMHere: A Novel mHealth System for Supporting Self-Care in

Management of Complex and Chronic Conditions, e10. In JMIR mhealth and uhealth

1 (2). http://mhealth.jmir.org/2013/2/e10/26

Secondary complications• Patients with chronic conditions (e.g. SCI) are

susceptible to secondary complications (UTI, wounds, etc.)

• Secondary complications lead to expensive hospitalization

• Promote a Wellness Program where a Wellness Coordinator (OT/PT/Nurse/community health worker) helps patients do self-care - works well!

• The program pays for itself (through saving from high-cost secondary complications)

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Physical Activity Monitoring: SCI

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Ayubi, Parmanto et al. (2014) A Persuasive and Social mHealth Application for

Physical Activity: Usability and Feasibility, In JMIR mhealth and uhealth (in press)

Two-way dynamic real-time communication

Dashboard/clinician portal

Apps

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MyMed: Medication Apps

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Skincare Apps

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Secure Messaging between Patient-Clinician

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Secure Messaging

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mHealth Components in Tele-Rehabilitation

• Secure bi-directional communication• Clinician-supported self-care: medication and

skin/wound care• Secure messaging between patient & clinicians• Sensor-based activity monitoring• Continuation of successful Remote Monitoring

features (needs these elements fixed before addressing Rehab issues)– Sleep and PTSD– Cognitive Behavioral Therapy– Personalized intervention

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Provide intervention when needed

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Cognitive Behavioral Therapy and Gaming: “Thought Buster”

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Results from Tele-Rehabilitation mHealth implementations

• Patients have been using actively and consistently (SCI);

– especially when mHealth apps support their daily self-care tasks

• Clinician-directed self-care support works:

– clinical outcomes are significantly better, wounds/UTI are prevented, hospitalizations reduced

– CBT for anxiety is better and takes shorter time than face to face

– Patients self-management skills are significantly better

• Scalable - capable of supporting large geographic coverage (currently still around 2 hours drive from Pittsburgh)

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Summary

• Telerehabilitation services can include evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching.

• Telerehabilitation services can be deployed across all patient populations and multiple healthcare settings including clinics, homes, schools, or community-based worksites.

• Due to the COVID-19 pandemic, the use of telehealth services has significantly increased and the growth of tele-rehabilitation as well.

• Further development in tele-rehabilitation will be dependent on resolving licensing and reimbursement issues.